Section 5

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Questions and Answers

What occurs if an oropharyngeal airway is too small?

The patient cannot breathe properly

The airway becomes obstructed (correct)

The airway allows free passage of air

The epiglottis gets displaced

Which of the following describes the correct placement of a nasopharyngeal airway?

Lying flat against the base of the tongue

Protruding beyond the uvula

Resting between the tongue and soft palate (correct)

Extending from the soft palate to the trachea

What is the primary function of a laryngeal mask airway (LMA)?

To inflate the trachea directly

To seal off the esophagus (correct)

To ensure ventilation through the mouth

To maintain an open airway in a conscious patient

What should be confirmed after placing a laryngeal mask airway?

Placement with breath sounds and chest X-ray Signup and view all the answers

What is an important feature of flow-inflating manual resuscitators?

They rely on gas flow for inflation Signup and view all the answers

How do permanent, self-inflating manual resuscitators differ from disposable ones?

They are designed for cleaning and reuse Signup and view all the answers

What should be monitored to assess lung compliance when using flow-inflating manual resuscitators?

The feeling of lung compliance Signup and view all the answers

Why is it important to ensure a nasopharyngeal airway is the largest possible size?

To minimize chances of obstruction Signup and view all the answers

What is one of the main functions of the Passy-Muir Tracheostomy Valve?

Allows speech while inspiring through the trachea Signup and view all the answers

Which of the following statements accurately describes the Kistner Button?

It has a one-way valve forcing exhalation through the upper airway Signup and view all the answers

What is the role of the Trach Button in post-tracheostomy care?

It maintains the stoma after tracheostomy removal Signup and view all the answers

When using the Olympic Trach-TalkTM device, what is a critical requirement to ensure proper function?

The cuff must be deflated to allow for exhalation Signup and view all the answers

What is a common challenge patients face when transitioning to a speaking or weaning device?

Fear, anxiety, or muscular weakness Signup and view all the answers

What is the primary purpose of the cuff in a cuffed tracheostomy tube?

Prevent air leakage and ensure ventilation Signup and view all the answers

Which tracheostomy tube type allows a patient to breathe through the upper airway when the inner cannula is removed?

Fenestrated Tracheostomy Tube Signup and view all the answers

What is the effect of a larger inner diameter on airflow resistance?

Decreases resistance Signup and view all the answers

What characteristic differentiates the Silver Jackson Tracheostomy Tube from other types?

It is reusable and made of durable material Signup and view all the answers

In the context of a cuffed tracheostomy tube with a disposable inner cannula, how frequently might hospitals typically change the entire tracheostomy tube?

Weekly, unless patency is questioned Signup and view all the answers

What is the primary purpose of high-volume, low-pressure cuffs in endotracheal tubes?

To exert minimal pressure on tracheal mucosa Signup and view all the answers

Which cuff pressure measurement technique involves auscultating the upper airway?

Minimal occlusion volume Signup and view all the answers

What is the main advantage of using a fenestrated tracheostomy tube during the weaning process?

It facilitates exposure of the lower airway to air Signup and view all the answers

Which tracheostomy tube type is most commonly used today due to its functionality?

Cuffed Tracheostomy Tube with a Disposable Inner Cannula Signup and view all the answers

What does the formula P = F/A represent in the context of artificial airway cuffs?

Pressure equals force divided by area Signup and view all the answers

What does the minimal leak volume technique aim to achieve?

Remove air until a small leak is audible Signup and view all the answers

What is a possible disadvantage of a cuffed tracheostomy tube?

It may cause pressure injury to tracheal tissues Signup and view all the answers

How is cuff pressure typically measured in clinical settings?

With a mechanical manometer or special manometers Signup and view all the answers

Which of the following is NOT a feature of the cuffed, disposable tracheostomy tube?

Allows for reuse after sterilization Signup and view all the answers

During what specific anatomical location is the incision for a standard tracheostomy typically made?

Between the 2nd and 3rd tracheal rings Signup and view all the answers

What type of endotracheal tube is designed for blind insertion and has a double lumen?

Combitube Airway Signup and view all the answers

What is the primary function of the pilot balloon in a cuffed tracheostomy tube?

To indicate cuff inflation status Signup and view all the answers

What is the general range for cuff pressure that is deemed acceptable in endotracheal tubes?

20-30 cm h2o Signup and view all the answers

What is the key benefit of using the Respironics PressureEasy device during ventilation?

It helps alleviate cuff leaks during inspiration. Signup and view all the answers

Which type of endotracheal tube facilitates easy removal and replacement of an existing tube?

Endotracheal Tube Exchanger Signup and view all the answers

What is the primary design function of the Miller laryngoscope blade?

To directly lift the epiglottis Signup and view all the answers

Which type of endotracheal tube is specifically used to prevent kinking during intubation?

Wire reinforced endotracheal tube Signup and view all the answers

What is the primary purpose of Magill forceps during intubation?

To grasp and manipulate the endotracheal tube Signup and view all the answers

How does Poiseuille's law relate the size of the airway to work of breathing (WOB)?

It states airway resistance increases significantly as airway radius decreases. Signup and view all the answers

Which device is primarily used to detect end-tidal CO2 during intubation?

End tidal CO2 detector Signup and view all the answers

What distinguishes the Carlens tube from other endotracheal tubes?

It intubates either the left or right mainstem with two cuffs. Signup and view all the answers

Which laryngoscope blade is designed to indirectly lift the epiglottis?

Macintosh blade Signup and view all the answers

What is a primary characteristic of Yankauer suction devices?

They are specifically designed for tonsil suctioning. Signup and view all the answers

When comparing cuffed and uncuffed endotracheal tubes, which statement is more accurate?

Cuffed tubes provide a better seal to prevent aspiration. Signup and view all the answers

For pediatric patients, what is the formula to estimate the appropriate endotracheal tube size based on age?

Age in years / 2 + 4 Signup and view all the answers

Study Notes

Oropharyngeal Airway

The posterior tip of the airway should rest at the base of the tongue
If the airway is too small, there is continued obstruction
If the airway is too large, the epiglottis will be held shut

Nasopharyngeal Airway

Separates the tongue from the soft palate
Use the largest size possible
The tip should rest between the tongue and the soft palate
If the airway is too small, there is continued obstruction
If the airway is too large, the epiglottis will be held shut

Laryngeal Mask Airway

The tip is designed to rest against the upper esophageal sphincter
Sides face the pyriform fossae, lying just under the base of the tongue
Seals off the esophagus
Ensure black line faces the upper lip
Placement should be confirmed with breath sounds, end-tidal CO2, and chest x-ray

Manual Resuscitators

Provide a means of delivering positive-pressure ventilation to a patient's airway
Ventilate bradypneic or apneic patients
Hyperinflate patients with oxygen before and after suctioning procedures
Generate airway pressures and large tidal volumes to expand atelectatic lung segments
Allow for the addition of positive end-expiratory pressure (PEEP) valves

Flow-Inflating Manual Resuscitators

Rely on gas flow to inflate them
Mostly disposable
May deliver 100% oxygen or any FiO2 if set on a blender
Little "built-in" resistance
Allows you to "feel" the lung compliance
Harder to bag indicates worsening lung compliance

Permanent, Self-Inflating Manual Resuscitators

Designed to be cleaned and reused

Mouth-To-Mask Devices

These are manually operated ventilators

Intubation Equipment

**Laryngoscopes and Blades **
- Miller laryngoscope blade - designed to directly lift the epiglottis
- Macintosh laryngoscope blade - designed to slip into the vallecula (indirectly lift epiglottis)
Equipment Used to Assist in Intubation
- Magill forceps
- Stylet
- Yankauer suction (tonsil tip)
- End tidal CO2 detection

Endotracheal Tubes

Cuffed and uncuffed tubes
Mallinckrodt Hi-Lo® Evac endotracheal tube - suction lumen just above the cuff
Wire reinforced endotracheal tubes - used to prevent kinking
Oral and Nasal RAE® tubes - have a bend to move the circuit from the airway
Endobronchial endotracheal tubes
- Carlens tube (2 cuffs, intubate L mainstem)
- Robertshaw tube (2 cuffs, intubate R or L mainstem)

The Importance of Poiseuille’s Law

Smaller airway = work of breathing
As radius is reduced by half, resistance increases by 16 times
This imposed work of breathing can be significant
Small artificial airways can make weaning from mechanical ventilation more difficult
Adults: Height dependent
- Female: 6.5 - 7.5
- Male: 7.0 - 8.0
Formula for Pediatrics: (age in years+ 16)/4 = approximate size of ETT

Larger inner diameter = less resistance

Smaller inner diameter = more resistance

Forces Exerted by Artificial Airway Cuffs

P=F/A
High-volume, low-pressure cuffs
- Endotracheal tube
- Trachs
- Volume = more surface area = less P to seal the tube against the tracheal wall
- Less pressure on tracheal mucosa
- Age cutoff for cuffs is 8 years (not absolute)

Cuff Pressure Measurement Techniques

Minimal occlusion volume
Minimal leak
Cuff Pressure Manometers
- Mechanical manometer & 3-way stopcock
- Posey cufflator
- DHD Cuff-Mate2
Measured/filled via pilot balloon

MLV vs MOV

Minimal Leak Volume
- Auscultate upper airway
- Add air to cuff until leak disappears
- Remove a small amount until leak is just heard again
Minimal Occlusive Volume
- Auscultate upper airway
- Add air to cuff until leak just disappears
Also called minimal leak/occlusive technique (MLT/MOT)

Cuff Pressure Manometers

Measure the pressure in the cuff used to seal the trachea
20-30 cm H2O
Calibrated to atmospheric pressure

Cuff Pressure Measurement Continued

Respironics PressureEasy
- Helps with tubes having a "leaky" cuff
- Adds pressure to cuff during inspiration, when it is needed most
- Utilizes positive pressure from ventilator
- Cuff pressure is reduced during exhalation

Murphy Eye

This is a small hole on the endotracheal tube that helps reduce pressure on the tracheal wall

Hi-Lo Evac Endotracheal Tube

This tube has a suction lumen just above the cuff which helps to remove secretions

Wire-Wrapped Reinforced ETT

This type of tube is used to prevent kinking

Right Angle Endotracheal Tube (RAE)

This tube has a bend that moves the circuit from the airway - It is often used for nasal intubation

Carlens Endobronchial ETT for independent lung ventilation

This tube has two cuffs that allow the left mainstem to be intubated

Robertshaw Endobronchial ETT

This tube has two cuffs that allow either the left or right mainstem to be intubated

Combitube Airway

Double lumen
- Esophageal gastric airway
- Endotracheal tube
Designed for blind insertion
2 cuffs (inflate both)
Ventilate through either port, confirming which produces chest rise and adequate ventilation

Combitube Insertion Video

There is a link to a Combitube insertion video. Please see the text for the link

Intubation Equipment Continued

Endotracheal Tube Exchanger
- Facilitates removal and replacement of an endotracheal tube
- Tube change is sometimes necessary due to:
  - Blown cuff
  - Upsizing
  - Damaged
- Threaded through old tube, remains in place when the tube is removed, new tube is fed over it.
- Guaranteed to go through vocal cords if the old tube was properly in place

Tube Exchanger

This device is used to help with the removal and replacement of an endotracheal tube

Tracheostomy Tubes

Bypass the entire upper airway
Incision is usually made between the second and third tracheal rings

Tracheostomy Tubes Continued

Cuffed, Disposable Tracheostomy Tube
Cuffed Tracheostomy Tube with a Disposable Inner Cannula
Fenestrated Tracheostomy Tube
Silver Jackson Tracheostomy Tube
Communi-Trach
There is a link to a tracheostomy video. Please see the text for the link

Cuffed, Disposable Tracheostomy Tube

Contains cuff and pilot balloon
No disposable inner cannula; entire trach is changed periodically
Usually made of PVC

Cuffed Tracheostomy Tube with a Disposable Inner Cannula

Most common now
Inner cannula is removable
No need to change the entire trach unless the patency of the cuff is in question
Many hospitals will change weekly

Fenestrated Tracheostomy Tube

Contains a removable inner cannula
When the inner cannula is removed and the balloon is deflated, the patient may breathe through the upper airway
Often used for weaning purposes
With the cuff inflated and the inner cannula inserted, mechanical ventilation is possible

Silver Jackson Tracheostomy Tube

May be used as a permanent trach
Cuffless and made from sterling silver
Silver is more durable and easier to clean
Not very common these days

Communi-Trach

a.k.a. Pitt Speaking Tube
Facilitates speech with an inflated cuff
Blows oxygen by vocal chords via fenestration
Patient may speak without using their own expiratory gas flow
Often difficult for the patient to coordinate
Speech is not "normal" sounding

Specialized Weaning Devices

Maintain patency of stoma during weaning
- Olympic Trach-TalkTM
- Passy-Muir Tracheostomy Valve
- Trach Button
- Kistner Button

Olympic Trach-TalkTM

A Briggs adapter with a spring-loaded valve
Allows the patient to inspire through the trach, but must expire through the upper airway
Trach cuff must be deflated! Otherwise, the patient could not exhale!

Passy-Muir Tracheostomy Valve

Small one-way valve that facilitates speech
Cuff must be deflated or patient cannot exhale!
Very common, some consider it the gold standard of speaking valves

Passy-Muir Valve

There is a link to a Passy-Muir Valve video. Please see the text for the link

Trach Button

Used to maintain the stoma after the tracheostomy has been removed
Consists of: inner cannula, plug, IPPB adapter, spacers
- Plug closes the stoma so the patient can breathe through the upper airway
- IPPB adapter allows mechanical ventilation (no cuff)
- Spacers adapt to varying neck thickness

Kistner Button

Trach button with a one-way valve
Cannot be used with mechanical ventilation
One-way valve forces the patient to exhale through the upper airway
- Facilitates speech
- Allows for a more effective cough

Secretion Evacuation Devices

Suction Regulators
Suction Catheters
AARC Clinical Practice Guideline: Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways

Suction Regulators

Use a single-stage regulator to reduce the high negative pressures from the supply line to safe physiological levels
Generally, we don’t need to go > 120mmHg
Must occlude to accurately read pressure!

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Description

Test your knowledge on oropharyngeal, nasopharyngeal, and laryngeal mask airways, as well as manual resuscitators. This quiz covers specifications and placement techniques essential for effective airway management. Evaluate your understanding of these crucial concepts in emergency medicine.